NIOSH Comments on the Review and Critique of the Site Profile Document for the Los 

Alamos National Laboratory by Ken Silver, D.Sc., S.M. 

INTRODUCTION 

As an expert on historical radiological records at the Los Alamos National Laboratory (LANL), 

the National Institute for Occupational Safety and Health’s (NIOSH) Office of Compensation 

Analysis and Support (OCAS) provided funding to Dr. Ken Silver to independently review its 

site profile of the Los Alamos facility. The site profile, which was developed by NIOSH in 

conjunction with Oak Ridge Associated Universities (ORAU), was prepared to provide technical 

guidance to health physicists involved in the reconstruction of radiation doses for claimants 

under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). Dr. 

Silver’s review report, issued on September 19, 2005, outlined four key issues that he believed 

are relevant to the information presented in the site profile. These are: 

1. Completeness and fidelity of the site profile’s retrieval and use of information in the 

public domain; 

2. LANL’s furnishing of access to information not yet in the public domain;

3. Ability of worker and community organizations to independently evaluate how cited 

sources of information have been analyzed and interpreted in the site profile document; 

and, 

4. Verification and assurance for individual claimants that no pertinent sources of 

information have been overlooked in performing dose reconstructions, as a matter of 

fairness.

The review provided by Dr. Silver focused on the content of the site profile in light of the first 

three issues identified above. In Dr. Silver’s opinion, a review of the site profile against the 

fourth criteria required access to the administrative record for rejected claims which was not 

available to him at the time of publication of the report. The fourth issue was, therefore, not 

evaluated in his report. 

General Comment

NIOSH appreciates the thorough review and critique provided by Dr. Silver. It is clear that his 

specialized knowledge of historical records at Los Alamos uniquely enables him to evaluate the 

inclusiveness and availability of the information contained in the site profile. While we agree 

with some of the issues raised in the review report, it was clear that some observations which are 

identified as significant failures to include certain data sets might be the result of a 

misunderstanding of the dose reconstruction process and how the site profiles are applied to 

individual cases. As an example, the report cites the failure to include the voluminous 

occurrence reports in the site profile as evidence that NIOSH dose reconstructions might not be 

truly claimant friendly. 
NIOSH’s approach to dose reconstruction has always been to provide the claimant with an 

estimate of dose that will allow the Department of Labor to arrive at the correct compensation 

decision (i.e., the probability of causation is on the correct side of 50%). To accomplish this, 

individual monitoring data has been given the highest emphasis. When reconstructing doses, for 

even infrequently monitored workers, the dose reconstruction will often rely on missed dose. 

That is, given the individual monitoring data, what is the maximum plausible dose that could 

have been received by the worker without being detected by the monitoring program. The use of 

this technique, coupled with the assumption of chronic exposure conditions where applicable, is 

inclusive of any exposure that might have been received as a result of an incident. For 

unmonitored workers, who were in exposure conditions where they should have been monitored, 

NIOSH applies a co-worker model that assumes these workers were exposed to the upper end of 

the distribution of results collected from the monitored population. 

Specific Comments

The following discussion provides NIOSH’s specific comments on issues raised in the report. 

The comments and responses are ordered to be consistent with the sequence of comments for the 

three key areas evaluated in the report. The comment or issue presented in the review document 

is provided, along with the page number it appears. The NIOSH OCAS discussion/response 

follows the comment and is followed by discussion of any significant impact that this might have 

on dose reconstruction. Where applicable, we have also included planned actions. The 

implementation of these actions will be coordinated with the review of the Los Alamos site 

profile currently underway by the Advisory Board. 

Section 1 - Completeness and fidelity of the site profiler’s retrieval and use of information 

already in the public domain. 

In this section, a number of issues are raised that relate to NIOSH’s failure to include 

information already made public by: 1) the Los Alamos Historical Documents Retrieval and 

Assessment (LAHADRA) project; 2) the 1991 Tiger Team report; and, 3) other information 

already in the public domain. 

Health Division Reports 

As excerpted below, there are several statements in the review report that are critical of the 

completeness of the Health Division reports contained in the site profile. The review points out 

that much more data than was reported in the site profile are in the LAHADRA collection and 

additional documents, that have also been made available to the public, are not represented. 

Page 12: The date of October 1960 as the “most recent” H-Division Progress Report is 

highly erroneous. 

Page 14: Ambiguity exists as to whether H-Division Monthly Progress Reports were 

issued after 1964. 

Page 15: The failure of the site profile document to consider the “H-1 Monthly Progress 

Report” in the late 1960’s and early 1970’s series is a serious omission. 

2 
NIOSH strives to utilize all available, relevant resources to complete dose reconstructions. At 

many sites, but not all, site profiles assist in the dose reconstruction process by providing dose 

reconstructors with a concise set of information to evaluate claims under the Energy Employees 

Occupational Illness Compensation Program Act (EEOICPA). Authors of the LANL site profile 

include members of the LAHDRA project, a program funded by the Centers for Disease Control 

and Prevention (CDC) to evaluate releases of materials that had the potential to cause off-site 

health hazards. This helps to insure that a broad scope of documents have been evaluated in the 

development of the site profile. It should be pointed out that not every document that was 

reviewed in the preparation on the site profile was cited, unless it was determined to be relevant 

to the accurate reconstruction of doses for workers at Los Alamos. 

Since the original site profile was prepared, the LAHDRA and ORAU teams have located many 

more Health Division reports. The available reports now cover the years through 1981. Many of 

these documents have been reviewed by LANL site profile authors for information useful to dose 

reconstruction. This review, which was completed in May of 2006, included all of the Health 

Division reports noted to be missing in the site profile. Those listed as missing became available 

to the LAHDRA project and NIOSH after the completion of the site profile document. A table 

that lists the Health Division documents available to NIOSH from the LAHDRA collection as of 

July 17, 2006 is provided in Attachment A. 

In light of this new information, chapter 2 of the Los Alamos site profile will be revised to 

accurately reflect the current inventory of Health Division reports that are available to NIOSH. 

As additional reviews of Health Division reports are completed, revisions will be made to the site 

profile to ensure that any new information is adequately represented. A revision to Chapter 2 

will be submitted by the site profile team to NIOSH by September 30, 2006. 

The following table provides a list of currently available Health Division reports that have 

already been reviewed by the site profile team: 

1947: May, July, August, September, October, November, and December 

1948: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1949: January, February, March, April, May, June, July August, October, November, and 

December 

1950: January, February, March, April, May, June, July, August, September, and October 

1951: January, February, March, April, May 

1952: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1953: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1954: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1955: January, February, March, April, May, June, July, August, September, October, 

3 
November, and December 

1956: January, February, March, April, May, June, August, September, October, November, 

and December 

1957: January, February, April, May, June, July, August, September, October, November, and 

December 

1958: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1959: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1960: January, February, March, April May, July, August, September, October, November, 

and December 

1961: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1962: January, February, March, April, May, June, July, August, September, November, and 

December 

1963: January, February, March, April, May, June, July, August, September, October, 

November, and December 

1964: February, April, June, July, August 

1965-

1980s 

Additional reports from this period have been or are currently being reviewed by the site 

profile team or are awaiting release from LANL record centers. These collections also 

include monthly, quarterly, and annual Health Physics reports for this and other specific 

time periods as the title and content of Health Division type reports changed over time. 

DOE Tiger Team report from 1991 

The 1991 report of the DOE Tiger Team assessment of LANL operations is cited as another 

example of information that was not considered in the site profile. The following excerpts from 

the review report are critical of the site profiles reliance on laboratory procedures and practices, 

rather than on available independent program reviews. 

Page 16: 1990 Tiger Team Report Not Considered......LANL technical reports and 

standard operating procedures describe how radiation doses “ought” to be 

measured.”...... “By willfully ignoring the Tiger Team report, the site profile 

document has, quite dangerously, repackaged the “ought” of LANL technical 

reports into a purported profile of what “is” (or was). 

Page 24: Standard Operating Procedures. The Site Profile’s reliance upon the Lab’s 

Standard Operating Procedures is an obvious blurring between “is” and 

ought”. Written SOPs are a technical community’s formal expression of how 

tasks “ought” to be performed...

4 
Standard operating procedures (SOPs) and technical reports are among the key documents used 

to prepare a site profile; however, many other documents and items of correspondence were 

reviewed in preparation of the site profile which do not fit the description of SOPs or technical 

reports. For example, much of the content of the LANL Photodosimetry Evaluation Book 

contains very basic documentation of how external dosimetry was actually practiced, “warts and 

all,” including a description of instances when practices deviated from standard procedures and 

steps that were taken to correct those practices and/or adjust measured doses accordingly. Many 

other LANL references used for the site profile report shortcomings of LANL’s radiation 

protection program. The site profile does not rely predominantly or exclusively on LANL’s 

“SOPs” and in fact uses raw or basic information wherever possible. 

The LANL site profile team reviewed the Tiger Team document for information that was 

potentially relevant to the dose reconstruction process. Many of the issues raised, such as 

angular dependence of LANL dosimeters or inadequate management of the dosimetry program, 

are either currently addressed in the site profile or are already accounted for by the dose 

reconstructors. These types of issues are often documented by NIOSH in technical information 

bulletins. Reports on biases in energy response characteristics and measurement uncertainties 

for LANL dosimeters are additional examples of LANL information cited in the site profile. 

Many of the technical shortcomings regarding internal and external dosimetry are known to 

exist, not only at LANL, but in the radiation protection community at large. The Tiger Team 

report does not address the programmatic elements in earlier years when the potential for intakes 

were likely more significant. As stated previously, many of these issues have already been 

addressed in the site profile document or have been addressed in Technical Information Bulletins 

(TIBs) or other project documentation. The combined information from the site profile, 

technical information bulletins, the computer assisted telephone interview (CATI), the claimant’s 

exposure records are all part of the dose reconstruction process. This multi-source approach 

ensures that technical issues and shortcomings, such as those raised in the Tiger Team report are 

addressed in the completed reconstruction. 

To be certain that all technical issues have been adequately addressed, the Tiger Team report was 

re-examined for content that may be applicable to the site profile. While the Tiger Team report 

provides much information related to radiation exposures, the limitations of monitoring data, and 

the inadequacy of LANL safety procedures, nothing has been found in the report that would alter 

the manner in which dose reconstructions are being performed for claimants from Los Alamos. 

Specific Examples of Tiger Team Technical Issues 

The site profile review provides a number of additional examples of specific technical issues in 

the Tiger Team report that, in the author’s opinion, might lead to idealized presentation of 

several technical issues. NIOSH’s evaluation of these issues is provided below. 

5 
Continuous Air Monitor Alarms

Page 18: Radiation Dosimetry CAM Alarms. Chapter 41 (“Internal Occupational 

Dose”) includes a discussion of continuous air monitors (CAM) alarms. 

Citing a report by LANL scientists, the site profile considers the suboptimal 

locations of CAM alarms: “when a worker causes a release and is at or near 

the release point, the worker could be exposed to intakes that did not trigger 

the alarms... However, the site profile does not consider numerous other 

mechanisms cited by the Tiger Team which cast serious doubt about the 

efficacy of the CAM alarms protecting LANL workers. 

In addition to the text cited above, additional explanatory information is provided in the Internal 

Occupational Dose chapter of the site profile. In this chapter, the text continues as follows: 

However, after 1970 when bioassay programs were well-established, the majority of 

workers with the potential for monitored and unmonitored intakes are expected to have 

participated in a bioassay program. 

While CAMs serve a purpose in providing information about general workplace conditions, they 

are not typically useful in a retrospective dose reconstruction because they may or may not be 

representative of a given individual’s exposure. Results of these measurements are more likely 

to be used when there is no other information available on which to base an assessment. For 

purposes of dose reconstructions under EEOICPA, however, a coworker approach would be 

utilized as the preferred option. 

Regarding comments on the efficacy of the alarms and other workplace mechanisms for 

protecting the workers, intakes that resulted due to a failure in these systems would be detected 

through the bioassay program. The default assumption when reconstructing the internal dose for 

radiation workers is that they were chronically exposed to airborne radioactivity; even 

individuals with no radioactive material detected in their samples would be assigned a missed 

dose. The missed dose is based on the intake that could have gone undetected by the bioassay. 

The internal dose chapter also points out that the potential existed at LANL for missed or 

unmonitored intakes/dose which directs the dose reconstructors (primary users of the site profile) 

to consider the use of NIOSH Technical Information Bulletins (TIB), coworker dose or worstcase exposures recorded at LANL. A coworker dose study is currently in process for LANL that 

is based on all available bioassay results from the site. This data set will be used to assign 

intakes to unmonitored individuals. Use of these alternative approaches to reconstruct doses in 

the absence of reliable individual monitoring data can be shown to result in conservative 

estimates of exposure. 

 

1

 The review document identifies the internal dose section of the site profile as Chapter 4. The internal dose section 

is actually in TBKS-0010-5, which is the 5th section or chapter of the profile. 

6 
Worker participation in a bioassay program

Page 21: DOE orders required contractors to identify workers for participation in a 

bioassay program. An Employee Health Physics Checklist (Form HS 2-

1A) was to be completed for each employee potentially exposed to 

radioactive materials......Instead the Tiger Team found a “low priority” 

was given to the requirement that radiation protection technicians review 

operations.

Chapter 5 of the site profile points out that the potential existed at LANL for missed or 

unmonitored intakes/dose which directs the dose reconstructors to consider the use of technical 

information bulletins, coworker dose or worst-case exposures recorded at LANL. This issue is 

largely being addressed by the dose reconstructors and is not exclusively by design addressed by 

the site profile. 

Other Tiger Team findings

As previously discussed, issues presented in the Tiger Team report related to external dosimetry 

are addressed either in the site profile, technical information bulletins, or other procedures. 

Content related to other issues presented in this section of the Tiger Team report, such as 

tracking of radiation sources and x-ray units, protection for accelerator workers, training and 

management of radiation protection technicians, and lack of calibrations of fixed and portable 

instruments, lacks sufficient specificity to be of use to the site profile authors. 

Site profile authors revisited the LANL Tiger Team Report and will include it as a reference in 

the revision to Chapter 2. No additional information from the Tiger Team, however, will be 

included in the revised site profile documents at this time. 

Worker recollections 

The site profile authors have worked extensively with William Moss and James Lawrence (both 

former LANL workers). Bill Moss (employed between the1950s – 1990s) was a radiochemist 

responsible for the urine bioassay analytical program and James Lawrence was the health 

physicist responsible for dosimetry and other programs (1950s – 1990s). Moss and Lawrence 

have had a significant positive impact on the site profile and both have helped to resolve 

questions regarding bioassay and external dosimetry. Site profile research team members will 

continue to work with Moss and Lawrence and other retired and active LANL workers as 

appropriate 

Worker outreach efforts, although off to a slow start, has significantly improved. NIOSH is 

committed to meeting with the line workers at the site and making sure that each and every 

comment brought forth at these meetings is addressed 

Other Important Publicly Available Documents 

Nyhan report

7 
The Nyhan report citation has been noted and will be reviewed for applicability to the site 

profile. Chapter 4 of the site profile addresses all available monitoring data including data 

collected at TA-21. 

History Associates report

The LAHDRA project reviewed this report and found the majority of the information already in 

the LAHDRA database or available through NIOSH. The impact of this report to dose 

reconstruction is not considered significant at this time. 

Site profile researchers revisited this work to ensure that all relevant information has been 

captured for use in the EEOICPA project. No additional useful information for the site profile 

was identified. 

Human Radiation Experiments

Human radiation experiments conducted as workers at Los Alamos, even if voluntary, is 

considered covered employment under EEIOCPA. The information concerning participation in 

these human studies is available and will be researched at the Human Subject Project Team 

(HSPT) archives. OCAS will research the information to assist with dose reconstruction for 

those involved. The site profile will be updated as necessary. 

Review of Apparent Inconsistencies between Sections of the Site Profile 

The site profile will be reviewed for inconsistencies among various sections and the will be 

revised as necessary. 

Section 2 - Incident and Occurrence Reports not Found in the Pubic Domain 

The major issue raised in section 2 is summarized in the excerpt provided below. 

Page 31: A principal shortcoming of the site profile document is the incomplete 

listing of incidents, accidents, and occurrences involving worker 

contamination. 

The purpose of the site profile is not to report every incident or accident (collectively referred to 

as occurrences) that ever occurred at LANL but rather to serve as a guide to dose reconstructors 

for uniformly assessing LANL claims. While it is known that some reported occurrences 

resulted in worker radiation exposures, it is also known that an equal or larger number of 

occurrences resulted in minimal or no exposures at all. The challenge always for the site profile 

authors is to decide which of the thousands of reported occurrences to present in the site profile. 

OCAS requested and received an excel sheet from Dr. Silver regarding incidents that occurred at 

LANL. This and other applicable references will be cited in the next revision to the site profile. 

For purposes of clarification, information presented in the site profile should provide useful data 

to the dose reconstructors for completing claimant dose assessments. To this end, the site profile 

8 
provides a summary of major events highlighting potentially significant releases or exposure 

events that occurred at LANL. Upper bound values for the types and magnitude of incidents that 

occurred can allow dose reconstructors to develop conservative intakes for both monitored and 

unmonitored workers. Research continues to identify the intakes for both maximizing and 

general conditions. Examples of intakes identified thus far are listed in Table 5-22 of the site 

profile. Other approaches being used to account for missed dose or assign dose to unmonitored 

workers include the use of co-workers data and other workplace survey data. 

For completeness, the ORAU team reviewed the available information in the LANL Occurrence 

Reports Collection at TA-35. Most of the information in these files was found to be related to: 

1) the levels of surface or air contamination resulting from an accident; 2) descriptions of efforts 

by LANL workers to decontaminate facilities; and, 3) statements about worker protection and 

monitoring measures. Although no information has been identified thus far that would change 

the approaches employed in dose reconstructions, reconstructors will be made aware of the 

existence of these records and encouraged to review them if it appears warranted for the specific 

case being reconstructed. Acknowledgement of this resource will be added to the internal 

dosimetry section of the site profile document. 

Section 3 - Ability of worker and community organizations to independently evaluate how 

primary sources of information have been analyzed and interpreted in the site profile 

document (p.39) 

Page iv: One of the cited sources, an internal LANL document that is not publicly 

available, sharply contradicts the official public record of workers’ 

collective doses at LANL established by the annual report series 

“Radiation Exposures for DOE and DOE Contractor Employees. The 

numbers reported by the site profile do not agree with DOE’s annual 

report for either the total number of persons monitored (which includes 

visitors) or the number of UC plus Zia employees monitored. The 

population dose (person-rems) in the site profile is systematically lower 

than the population dose reported in DOE’s annual report for UC plus Zia 

employees. The site profile document furnishes the Lab’s new numbers 

without even citing the DOE report series. The Lab’s numbers are from a 

cited source with no “LA-“ report number. The Lab’s numbers for annual 

person-rems are systematically lower. This reinforces an impression 

gained by some workers over the course of their careers at LANL that 

“the books are cooked.”

Two files of historical external radiation dosimetry data were supplied to Tom Widner (Site 

Profile Chapter 6 primary author) by John Voltin and Kenneth Rowlison of LANL on July 26 

and 29, 2004. The first file contains the following values for each calendar year from 1944 to 

2004 (with 2004 being based on the partial year of data in the system at the time of reporting): 

• Exposure Year 

9 
• Under each year, values for the following for each (unidentified) person with non-zero 

dose of any kind: (1) Deep dose total (mrem), (2) Shallow dose total (mrem), and (3) 

Neutron dose total (mrem). 

• The total number of persons with any non-zero dose 

• Collective deep dose, shallow dose, and neutron dose (mrem) 

The second file contains the following values for each calendar year from 1944 to 2004: 

(1) Year, (2) Number of Employees Monitored, (3) Collective Deep Dose (person-mrem), and 

(4) Collective Neutron Dose (person-mrem). 

An analysis of the LANL neutron-to-photon dose data (from the first data set described above) 

was performed by Jack Fix and colleagues at PNNL. Because the purpose of their analysis was 

to obtain the most definitive data available concerning values of neutron dose divided by deep 

dose, only those data where both the deep and neutron doses were equal to or greater than 50 

mrem were included in the analysis. 

The data provided by LANL to DOE’s annual report series was examined and the reasons for the 

differences were evaluated. The values presented in Table 6-2 of the site profile represent 

external radiation doses. The values for LANL reported by DOE (such as in DOE/EH-0287P for 

1990) were total doses, external plus internal. The numbers of workers monitored that are given 

in Table 6-2 include all persons that were monitored, in accordance with modern-day reporting 

guidelines, including workers in the following categories: LANL, Johnson Controls Inc. 

(analogous to Zia Company in earlier years), visitors, subcontractors, and DOE’s Los Alamos 

Area Office. In accordance with the requirements of DOE Order 5484.1 at the time, LANL did 

not include subcontractors or visitors with zero doses in the numbers of workers reported each 

year. 

Availability of reports to the public 

Page 17: ... the fact that many of the cited LANL technical reports are inaccessible 

... makes it impossible for citizens’ or workers’ organizations to mount an 

incisive challenge to management’s idealized picture of “ought,” which 

the site profile now proffers as reality.

Page 42: Finally, 78 (30.7%) of the 254 cited sources in the site profile are not 

available to the public using the open literature, ECDB, Opennet, or 

CDC-ChemRisk. Among these items are LANL Photodosimetry Evaluation 

Book (“the Bible”), Inkret’s numerous technical reports on dosimetry 

practices (1998-1999), LANL Health Physics checklist (2004), Lawrence’s 

numerous dosimetry reports (1967, 1984, 1990, 1992). 

While NIOSH strives for transparency in our activities under EEOICPA, there are legal and 

logistical constraints that preclude us from making all reports accessible on our website. As 

many of the documents contain personally identified information that is subject to the provisions 

10 
of the Privacy act, they could not be published without the redaction of all such information. In 

addition, some documents are designated as “official use only” which would preclude NIOSH 

from widely disseminating them among the public. As with all program documentation, 

Freedom of Information Act (FOIA) requests have been and will continue to be responded to in 

accordance with the applicable requirements. 

11